January 10, 2017

WSJ: Siri, Am I About to Have a Heart Attack?

ObamaCare was always about paying for health care—costs have outpaced inflation for decades—but seldom about keeping people healthy. As Republicans repeal and replace, they need a vision for the path to better care. Technology now exists to provide cheaper and higher-quality health care, but giant roadblocks stand in the way.

That technology is artificial intelligence and machine learning. The algorithms behind AI are painfully complex, but the final product is simple—think Google Translate or Amazon’s Alexa. Saying a phrase and immediately having it translated is cool. Being told that your week of bad sleep and slight stomach pains could be cancer is life-altering.

Machine learning is already invading health care. Experts at Kaggle, an artificial-intelligence research firm, shared a few real-world applications of the technology with me: Predicting heart failure by looking at massive amounts of MRI scans, diagnosing diabetic retinopathy from eye imaging, and successfully predicting seizures with a machine analyzing electroencephalogram data.

The key is data. With more of it, accuracy gets better over time. At least on the surface, the Obama administration did something right—the Health Information Technology for Economic and Clinical Health, or Hitech, Act. Part of the 2009 stimulus largess, it set aside some $20 billion worth of incentives for hospitals and doctors to show “meaningful use” of electronic health records, or EHRs.

Tons of data come with medical records. Then there are digital scales, Fitbit steps, WellnessFX blood tests, Apple iWatch data and 23andMe genetic test results. Eventually there will be daily commode sensors measuring blood sugar and prostate-specific antigen levels, among other things. Now imagine all that data being crunched, in real time, by machines looking for patterns—which then put out a simple text message. “Your Hemoglobin A1c has spiked again. I thought we agreed to cut back on the linguine.”

Describe this to anyone in health care and you’ll get two words back: Dream on. Instead of advancing electronic health record “interoperability”—a fancy word for being able to share and access electronic health records—the Hitech Act ended up as a funding mechanism for electronic health-record firms like Epic Systems, Cerner and Allscripts. By 2016, the government scheduled $23.8 billion in payments for firms that could achieve full electronic access and true interoperability for the full calendar year. It was later changed to a much easier 90-day reporting period for a subset of patients. Call it meaningless use, but the money kept flowing.

If you try to transfer your records from one hospital to another or to a doctor, you’ll probably end up “walking with paper,” as they say in the industry. The average doctor still deals with reams of faxes every day. A friend tried to send records from a Boston hospital to Miami; both places use Epic Systems’ electronic files. The records were faxed.

Epic Systems, a private company based in Verona, Wis., is the industry leader, controlling close to half of all American medical records. Still led by 73-year-old founder Judy Faulkner, Epic also appear to be the leading obfuscator when it comes to transferring records and interoperability.

In 2015, competitors Cerner, Allscripts, Athenahealth and others have set up a group known as CommonWell Health Alliance to ensure health IT interoperability. Epic, with annual revenues easily north of $1 billion, refused to join, citing the $1.4 million upfront fee and $900,000 annual payments. Oh, and Epic didn’t want to sign the nondisclosure agreement.

My industry sources tell me Epic won’t sign nondisclosure agreements with anyone but makes outsiders agree to them. The company doesn’t co-develop applications with outside companies. Third parties don’t have access to application programming interfaces, APIs, which are the gateway for record data. Hospitals and doctors can have access, if they beg hard enough, but then they must hire inside developers to customize their system.

The company avoids titles, but good luck contacting any of its 9,000 employees, who are forbidden to give out their cellphone numbers. Epic has one phone number to the main switchboard. It’s still the 1970s in many ways.

I called it. Eric Helsher, vice president of client success at Epic, responded: “Today 100% of health systems using Epic are sharing patient information to better care for patients. They exchange over 1.3 million patient records a day and interoperate with all major EHR vendors and government agencies.”

Epic is talking up something it calls the App Orchard, a portal for vendors to sell apps that dig into Epic’s electronic records. Except the proposed pricing comes to four cents per message sent. Machine learning would drive millions or billions of messages. The company might cap fees at 30% of the vendor’s revenue: Even Apple isn’t that greedy.

I’m trying to get my medical records from a hospital with Epic systems. The best I have been able to do is a PDF file, a modern way of walking with paper.

How do we fix this? Dr. Eric Topol at Scripps in San Diego proposes health records be patient-owned and controlled, perhaps on a flash drive or iPhone or in the cloud. Maybe next to health savings account info. It’s a start.

But forget government mandates. The real incentive is insurers paying for this data, and they are figuring out that early detection is worth it. It’s a lot cheaper to find a disease before it turns into expensive chronic care for heart disease or cancer. The machine learning output might be: “You may have pre-Stage 1 cancer in your pancreas, but no worries—we can zap it out for you.”

That’s how you bend the cost curve in medicine. Make firms like Epic look at interoperability as an incremental profit center rather than an opening for competitors. The dream of smart machines crunching health info is real. Don’t let the dream walk with paper.